Emerging Issues in Medicaid Mental Health Services

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Emerging Issues in Medicaid Mental Health
Services

• Jeffrey A. Buck, Ph.D.
• Jeff.buck_at_samhsa.hhs.gov

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The Basics

• Medicaid is the largest payer of MH services in
  the nation.

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Medicaid is the largest MH Payer
MH100 billion (2003)
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Medicaid is nearly half of all public MH spending
2003 58.3 bil.
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MH service users make up a major portion of high
cost Medicaid enrollees
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for MH Users as a of for All High Cost
Medicaid Enrollees
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Emerging Issues

• Nonspecialty psychiatric care
• Nonpsychiatric comorbidity
• The changing State MH Agency
• Data interoperability
• Impact of changing Medicaid policy on the MH
  system

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Emerging Issue

• Nonspecialty Psychiatric Care

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Majority of Medicaid MH Spending is for
Nonspecialty Care
2003 26.4 bil.
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Major Nonspecialty MH providers in Medicaid

• ERs and general hospitals w/o psychiatric units
• Nursing homes
• Nonpsychiatric physicians
• Psychotropic drugs

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AHA Behavioral Health Task Force

• . . . hospital CEOs report a dramatic increase
  in the average length of stay for emergency
  department (ED) patients requiring psychiatric
  admission. Many hospitals report an increase in
  ED boarding of patients with behavioral health
  disorders.

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AHA Behavioral Health Task Force

• The 24/7 availability of the hospital emergency
  department makes hospitals the safety net or
  provider of last resort for behavioral
  healthcare.
• Many patients with severe behavioral health
  disorders seek care in general hospitals that are
  designed for short-stay medical-surgical
  patients.

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Nursing Homes - News item

• Janet Wells, public policy director for the
  National Citizens' Coalition for Nursing Home
  Reform, said nursing homes had become the new
  dumping ground for psychiatric patients. "These
  people should not be in nursing homes," she said.
  "They should be somewhere where they're getting
  treatment. Instead, they're just being cast
  aside."
• NY Times, 12/03

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Nonpsychiatric Physicians(Wang et al., 2006)

• General medical-only service sector experienced
  the greatest increase over the 90s and is now
  the most common
• MH specialty (other than psychiatrists) decreased
  along w/human services
• General medical w/ and w/o other MH specialty was
  also most frequent for the most serious disorders

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Service Use Patterns

• Multiple studies show that many MH patients
  prefer treatment in general medical settings
  only a minority see a specialist
• When primary care patients are referred to MH
  specialty care, only a third to a half follow
  through
• PCPs often substitute alternative diagnostic
  codes

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Medicaid Psychotropic Drug Prescriptions by
Nonpsychiatric Physicians

• All psychotropics 60
• Antidepressants 61
• Stimulants 62
• Antipsychotics 34
• Source Unpublished 2004 IMS data

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Emerging Issue

• Nonpsychiatric comorbidity

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Comorbid conditions

• Jones et al. (2004) - 74 of persons with serious
  mental illness in Medicaid had at least one
  chronic health problem 50 had two or more
• Another Medicaid study found that of different
  pairings of chronic co-morbid conditions,
  psychosis was a factor in 5 of the 7 highest cost
  pairs

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Emerging Issue

• The changing State MH agency

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State MH Authorities (SMHAs)

• SMHAs are decreasing their role in
  inpatient/institutional care
• In 1981, about 2/3s of SMHA spending was for
  hospitals by 2003 this had dropped to less than
  a third
• State hospital beds are less than half what they
  were in 1986
• More state hosp are for forensic care (25)

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SMHAs (contd)

• More of what SMHAs do is administering part of
  the Medicaid program
• From 1987 to 2003, the percentage of all SMHA
  budgets from Medicaid went from 13 to 39 percent
  (range 0 87)
• In 12 states this was more than half
• In 22 states more than half of SMHA community
  spending is from Medicaid

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Nevertheless, MH Agencies manage only a minority
of Medicaid MH
Medicaid MH Spending (est)
2003 Total 26.4 bil.
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Emerging Issue

• Data Interoperability

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MH and Medicaid data incompatibility

• SMHA and Medicaid data are limited in their
  compatibility - differences in data elements and
  coding mean that identical service events cannot
  be identified with confidence
• Only 16 states report efforts to link MH and
  Medicaid data

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Emerging Issue

• Impact of changing Medicaid policy on the MH
  system

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Sources of policy changes

• Deficit Reduction Act
• Audits
• More aggressive enforcement
• Challenges to longstanding practices
• Broader regulations

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Possible Effects

• Increase in oversight of MH by Medicaid agency
• Greater accountability for MH service providers
• Increase in incentives for smaller child
  residential facilities
• Reorganization of MH rate-setting, payment, and
  administrative systems

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Conclusions

• Mental health issues are integral to the Medicaid
  program and cant easily be segregated fm other
  services/problems
• Medicaid agencies may have to assume more
  responsibility for these services
• Effective administration/financing of State MH
  services require collaboration between Medicaid
  and MH agencies and effective coordination of
  spec and non-spec care

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